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NEWS & VIEWS |
Researchers led by Virginia P. Quinn, PhD, of Kaiser Permanente Southern California, were looking to measure physician compliance with the "5A’s" of tobacco cessation treatment promoted by the U.S. Public Health Service: Asking patients about tobacco use, Advising smokers to quit, Assessing smokers’ willingness to try quitting, Assisting smokers with cessation treatment and referrals, and Arranging follow-up contacts. They published their findings in the American Journal of Preventive Medicine (2005;29:77–84).
They sent questionnaires to 64,764 health plan members. Of the 41,677 eligible responses, 4,207 smokers were identified. Participants reported whether their health care provider had asked their smoking status at their last outpatient visit, advised them to quit, explored whether they felt ready to quit, and offered help through referrals to counseling or classes, pharmacotherapy, or self-help materials. They were also asked about physician follow up.
Seventy percent of those who responded to the survey were White, and nearly 64% were women. Nearly 74% of respondents were aged 55 years or younger. Almost 70% said they intended to quit smoking in the next 6 months, and nearly 27% said they had asked their doctor for help quitting in the past year.
The researchers found that physicians were highly compliant with the first two of the 5A’s: asking and advising. Fully 90% of smokers said their doctor had asked them about smoking in the past year, and 71% said their doctor had advised them to quit. But only around half were assessed for their willingness to quit (56%) or given assistance quitting (49%).
"It’s good news in that relative to 10 to 15 years ago, many more primary care physicians are identifying patients who smoke and advising them to quit," Quinn said of the findings. "What the study did show is that to comply with the health plans’ own guidelines, in addition to the national guidelines, doctors have to do more than ask and advise. They need to provide the effective tobacco treatments covered by their health plan."
The nine HMOs included in the study all provide comprehensive coverage for tobacco-related counseling and medication, the study noted. In addition, they all have their own guidelines for tobacco cessation, as well as staff, budgets, and oversight committees dedicated to cessation.
"Smoking remains the no. 1 modifiable risk factor for many serious diseases," Quinn said. "Tobacco cessation treatment is one of the most cost-effective medical services that health plans can provide."
Yet the study suggests that service often does not extend to follow up when a smoker has made a quit attempt. Just 9% of smokers surveyed reported any follow up on their status.
Quinn said the effectiveness of cessation treatments makes follow up appropriate—and it does not have to be the doctor who does it. Nurses, nurse assistants, or cessation counselors can follow up with patients, or patients can be referred to quit lines that include follow up in their services.
"But it’s up to the health plans to provide the clinicians with the support they need to do this effectively," Quinn pointed out.
Quinn and her colleagues noted differences in physician compliance with the 5A guidelines depending on whether the smokers had asked for help quitting or not. Among those who had asked for help, 81% said their physician had advised them to quit, and 81% said they had received quitting assistance. By contrast, 67% of those who did not ask for quitting help were advised to quit, and 37% were given cessation assistance.
Perhaps not surprisingly, asking for help quitting was the strongest predictor of being offered cessation assistance. However, only 27% of smokers reported asking for help the previous year, and among those who were planning to quit, only one-third asked for help.
"When smokers ask for help, they’re highly likely to get it, but that’s really not enough," Quinn said. "Doctors have to be proactive and not wait for patients to ask for help."
Tobacco cessation aids like counseling and medication can double the number of people who successfully quit, Quinn noted. But the fact that so few smokers asked for quitting assistance suggests they may not realize how helpful these treatments are or may not know what treatments their health plan covers. Doctors and health plans should encourage smokers to ask about these topics, she said.
Smokers who received tobacco cessation treatment—whether they intended to quit or not—reported higher satisfaction with their health plans than those who received no such treatment. That finding should allay physicians’ fears of nagging their smoking patients about quitting, Quinn said.
"There’s widespread belief in the medical culture that smokers don’t want to be bothered, and doctors don’t want to alienate their patients, but we found just the opposite of that," Quinn said. "Smokers expect doctors to address smoking and are more satisfied with their health plans when doctors do that."
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